Ocular Inflammation and Infection

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Key points

  • Blepharitis is treated with warm compresses and washes with mild soap; antibiotics should be considered for severe cases.

  • Episcleritis is usually mild and self-limited; Scleritis can be severe and has an association with numerous systemic diseases.

  • Chlamydia trachomatis presents initially as a watery discharge and progresses to a purulent discharge. Marked chemosis and eyelid swelling are present. Concurrent chlamydial pneumonia should be considered. Infected infants should be treated with oral

Hordeolum

A hordeolum (Fig. 1) is a pustular swelling of the lid margin, which is usually caused by Staphylococcus aureus. An internal hordeolum is a meibomian gland obstruction with infection. An external hordeolum (synonymous with a sty) originates from a hair follicle or tear gland on the lid margin. Both forms usually resolve in about 1 week. Treatment consists of warm compresses. Although data on effectiveness are limited, antibiotic ophthalmic ointment may be considered. A hordeolum may develop

Chalazion

A chalazion is a nodular, granulomatous swelling of the eyelid caused by an obstruction of a meibomian gland or a gland of Zeis. It is usually not painful. The presentation is usually subacute or chronic, but it can be acute. A chalazion may develop from a hordeolum. Distinguishing the 2 may be impossible in the acute care setting. Treatment consists of warm compresses. Because a chalazion is often chronic, time to resolution is likely longer than with a hordeolum. Referral to an

Blepharitis

Blepharitis is chronic eyelid irritation and inflammation. Its cause is complex and still not entirely understood. Factors generally thought to contribute to this condition include microbial organisms (S epidermidis being primary), abnormal lid margin secretions, and abnormalities of the tear film.1 Blepharitis has an association with atopic dermatitis, rosacea, and eczema.2 Symptoms are multiple and varied, including irritation, tearing, pruritis, and flaking or crusting of the eyelid. The

Scleritis and episcleritis

Scleritis is inflammation of the sclera, whereas episcleritis is inflammation of the lining of the sclera, or episclera. Both have symptoms of blurred vision, photophobia, tearing, and severe pain, which tend to be worse at night. Episcleritis is usually mild and self-limited. Scleritis is often more severe and has a much higher association with systemic diseases such as Wegener granulomatosis, rheumatoid arthritis, and connective tissue disease. Scleritis also has a higher association with

Keratitis

Keratitis is inflammation of the cornea of the eye. It often induces intense pain. The primary causes are bacteria, viruses, and UV radiation. It also has fungal and amoebic sources. Exposure keratitis is caused by incomplete closure of the eyelid.

Bacterial causes of keratitis include S aureus, Pseudomonas aeruginosa, coagulase-negative staphylococci, diphtheroids, and Streptococcus pneumonia; polymicrobial infections have been reported as well.8 Contact lens users are at increased risk for

Dacryostenosis

The nasolacrimal duct drains tears from the eye. An obstruction of this duct is known as dacryostenosis, which is very common in newborns and usually resolves spontaneously. This condition is not associated with erythema. Massage is first-line treatment. Continued obstruction may require probing by an ophthalmologist.

Dacryocystocele

A dacryocystocele or dacryocele is a fluid collection in the nasolacrimal duct caused by blockage of the proximal or distal portions of the duct. Patients present with a bluish-gray mass at the medial canthus. Initial treatment is gentle digital massage. Ophthalmologic referral is required, as there is an association with intranasal polyps.

Dacryocystitis

Dacryocystitis (Fig. 2) is inflammation and swelling of the lacrimal sac from acute infection. The most common causative organisms include S aureus, S pneumoniae, Haemophilus influenzae, Serratia marcescens, and P aeruginosa.13 In one study, 17.4% of cases of acute dacryocystitis were caused by methicillin-resistant S aureus (MRSA).14 In infants, acute dacryocystitis represents a medical emergency, because it can lead to severe complications, including orbital cellulitis.15 Cultures should be

Cellulitis

Cellulitis of the tissue surrounding the eye can be divided into periorbital and orbital categories (Fig. 3). Of the 2, a periorbital presentation is much more common. A distinction between them must be made, as orbital cellulitis can threaten both vision and life. Periorbital cellulitis is located anterior to the orbital septum. Orbital cellulitis is located posterior to the orbital septum but does not include the globe. The distinction can often be difficult and even impossible in the early

Conjunctivitis

Conjunctivitis is a common cause of red eye presenting to the emergency department. The most common cause of conjunctivitis is infection. In children, bacterial conjunctivitis is more common than viral.28 In adults, viral conjunctivitis is more common. Allergic, fungal, toxic, and chemical sources are also possible. Both viral and bacterial causes are highly infectious. Examination reveals injected bulbar conjunctiva. Other causes of red eye should be excluded before making the diagnosis of

Iritis

Inflammation of the anterior portion of the uvea is known as iritis. Symptoms include pain, blurred vision, and consensual photophobia, which is pain in the affected eye when light is shined in the unaffected eye. The examination is significant for eye redness and may show a constricted, poorly reactive pupil. Slit lamp examination may show WBCs and flare in the anterior chamber. Fluorescein staining should be performed, as a corneal abrasion, foreign body, or ulceration might be present.

Hypopyon

A hypopyon occurs when exudate collects in the anterior chamber. It is seen as a yellow-white exudate that collects in the lower portion of the anterior chamber because of gravity when the patient is upright. A hypopyon is generally sterile, void of pathogens. The differential diagnosis includes iritis, corneal ulcer, endophthalmitis, and fungi. Treatment is directed at the cause.

Corneal abrasion

A corneal abrasion is a defect to the corneal epithelium caused by trauma, foreign body injury, or contact lens use. Patients complain of severe pain and the sensation of a foreign body. Diagnosis is usually made by eliciting a history of trauma or a foreign body and confirmed with examination. Visual acuity may be normal. On examination, the pupil is typically found to be constricted due to reactive miosis. Fluorescein staining demonstrates an area of epithelial defect. Particular attention

Corneal ulcer

A corneal ulcer is caused by a break in the epithelium of the cornea, initiated by trauma or an infection. Patients have pain, tearing, photophobia, and a foreign body sensation. Staphylococcus and Streptococcus species are the most common pathogens in noncontact lens wearers. In contact lens wearers, Pseudomonas and fungi are common pathogens.47 Ulcers are more common in people who wear contact lenses, specifically soft contact lenses. Review of the patient’s medication history may reveal the

Summary

Ocular inflammation and infection may involve any part of the eye and surrounding tissue. A complete examination, including visual acuity, extraocular movements, pupillary response, intraocular pressure, slit lamp examination, and fluorescein staining, is often required to establish the diagnosis. Adequate pain relief may be achieved with oral analgesics and cycloplegics. Topical anesthetic drops should not be prescribed. Patients should be advised to avoid rubbing their eyes or straining them

Acknowledgements

This manuscript was copyedited by Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine at the University of Maryland School of Medicine.

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